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Abstract

Background

Early recognition of sepsis and designing a huddle process are key drivers of the Improving Pediatric Sepsis Outcomes (IPSO) collaborative. Our tertiary care, free-standing, pediatric hospital joined the IPSO collaboration in 2016. Our hospital began piloting Situation Awareness (SA) Escalation Huddles in 2016, to improve recognition of patients with clinical deterioration. The tool triggers if a patient has a high PEWS(> 5), requires initiation of hi-flow nasal cannula, or for staff/parental concern. The SA paper tool guides the communication process and steps of the huddle. Huddles include a nurse, provider, and respiratory therapist. One of the goals of the SA escalation huddle is to decrease the amount of Advanced Life Support code blue events and rapidly identify sepsis patients on the inpatient units. Prior to this study there was no formal screening process for sepsis in the inpatient units.Objective

In Fall 2017, a question “Sepsis Concern?” was added to the SA tool to better identify septic patients. Roll out of new SA tool was completed in a step-wise process throughout the hospital and completed January 2018 in all units. We collected the number of PICU transfers with + SA tool. We hypothesized this change should lead to timely identification of sepsis, care team huddle with bedside discussion, treatment, and escalation of care. Sepsis clinical practice guidelines and order-sets were developed in conjunction to aid in the decision making process.ResultsThere were 162 number of severe sepsis patients treated from September 2017 to March 2018 in our hospital. There were an average of 23 severe sepsis patients each month. 21% (34/162) of these patients were identified to have possible sepsis on the inpatient units.

From September 2017 to March 2018, 1,012 SA tools were triggered with a mean of 4.8 huddles/day. The average patient had an average 2.3 (1,012/445) SA huddles during their hospitalization. Of SA triggers, 49 huddles (over 34 patients) screened positive for “Sepsis Concern?”(4.8%,49/1,012). 71% of “+ Sepsis Concern” episodes were treated as possible severe sepsis (35/49). Of the “+ sepsis concern” patients, 29% (10/34) were transferred to the ICU. When completing the SA form 13.3% (135/1,012) skipped the “Sepsis Concern?” question.

During the study, 21% of PICU transfers for possible severe sepsis had the SA tool used (3/14) prior to transfer.

Conclusions

The majority of sepsis patients identified with the SA tool had severe sepsis and required ICU care. Ideally the “concern for sepsis” question would generate a shared mental model in the diagnosis and treatment of sepsis, however even questioning the possibility of sepsis and discussion about sepsis remains challenging.

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Children's Mercy, located in Kansas City, Mo., is one of the nation's top pediatric medical centers. The not-for-profit hospital provides care for children from birth through the age of 21, and is ranked by U.S. News & World Report as one of "America's Best Children's Hospitals.“
Visit childrensmercy.org